Download Medical Abortions

Medical Abortion: Options in an
Outpatient Setting
Objectives
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Pharmacology
Eligibility for medical abortion
Describe the process of consent, counseling,
administration, complications, and follow-up of
medication abortions.
Understand the role of medical abortions in the
context of Family Practice Clinics
Describe the process taking place to increase
access to medical abortions within CCRMC
Data from US Abortion
Surveillance, 2005
• Induced abortion rate peaked during the ’80’s,
23-24/1000, was 20-21/1000 in the ’90’s and in
’05, 15/1000.
• 2% decline from 2004
• 61% were less than 8 weeks EGA
• 87% were less than 12 weeks EGA
• 81% were known D&C/D&E
• 10% were MABs (increased from 1% in 2000)
• 94% of MABs were less than 8 weeks EGA
• There has been a steady increase in ABs <6
weeks, with a decrease in ABs 7-10 weeks.
MMWR, 2008
Pharmacology
Mifepristone
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A progesterone blocker
Interferes with placental attachment
Causes uterus lining to thin
Stops growth of embryo
Misoprostol
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Also called Cytotec
A prostoglandin E1 analog
Stimulates uterine contractions
Causes cervical ripening
Mifepristone Regimens
FDA Product Labeling
Gestational Age Limit
Evidence-Based
Protocol
63 days
Mifepristone dose
200 mg. oral
600 mg. oral
Misoprostol dosing
800 mcg. vaginal
49 days
Office follow-up visit
400 mcg. oral
Home self-administration Office administration
6 - 72 hours later
48 hours later
Day 4-10
Day 10-15
Minimum office visits
2
3
Cost of medications
$90 for mifepristone
$4.00 for misoprostol
$270 for mifepristone
$2.00 for misoprostol
Contraindications to
Mifepristone + Misoprostol
• Confirmed or suspected ectopic pregnancy
• IUD in place (must be removed before
treatment)
• Adrenal failure
• Current long-term systemic corticosteroid
therapy
• Allergy to mifepristone
• Hemorrhagic disorder or current anticoagulation
• Inherited porphyria
• Allergy to misoprostol
Additional Screening
• The decision is uncoerced
• EGA is less than 63 days
• Patient has the time and resources for
reliable follow-up
• Able to understand the instructions
Comparison of medical vs surgical abortion
• Offered up to 63 days
EGA
• Approx. 2 office visits
• 95-99% effective
• Depending on facility,
offered up to 12
weeks, or later
• Approx. 1 office visit
• 98% effective
Safety and cost are similar between the two
Comparison of medical vs surgical abortion:
Advantages
• May feel more natural
• No shots, anesthesia,
instruments, or
machines
• Can end pregnancy
earlier
• Privacy of home
• Initiated by the
woman
• Quick and over in a
few minutes
• Slightly higher
success rate
• Less bleeding
• Medical staff present
The Access Project
Comparison of medical vs surgical abortion:
Disadvantages
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Takes several days
Not as predictable
Heavier bleeding
More severe
cramping
• Slightly lower success
rate
• Side effects of meds
• May need surgical
follow-up
• Invasive
• Side effects of
anesthesia
• Woman has less
control over
procedures
• Cannot be done as
early
The Access Project
Logistics of Administration
• Confirm pregnancy
– Urine HCG and/or sonogram
• Confirm gestational age
– LMP history
– bimanual exam
• Lemon 5-6 weeks
• Orange 7-8 weeks
• Grapefruit 9-10 weeks
– sonogram
• Rule out ectopic pregnancy
Counseling: What to Expect
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Preparation is the key to a successful outcome
Pain
Bleeding
Side effects of medications
Support
• There must be surgical back-up, readily
available.
Follow Up Visit
• Schedule 1-2 weeks after initial visit
• Confirm completed abortion
– Criteria #1:
• History
• Pelvic exam
• Falling HCG
– Criteria #2
• History
• Repeat ultrasonography
Indications for Aspiration
• Approximately 2-5% of patients treated
with mifepristone+misoprostol will need a
follow up aspiration.
• Aspiration is most often done to
– Resolve an incomplete abortion
– Terminate a continuing pregnancy
– Control bleeding
The two key elements for successful
outcomes are:
1) Appropriate screening
2) Thorough counseling
Satisfaction depends on an informed choice
NAF abortion textbook
Advantages of Primary
Care Providers doing MABs
• Continuity
• Increase access to abortion, especially in
underserved areas
• Expand options
• Safe and efficacious
– In a retrospective case series, of 236 MABs
performed in 4 community health centers (majority
managed by family physicians) only 1 pt. required
aspiration, a failure rate of .4%. (Prine et al.)
• MABs require key PCP skills: assessing a
patient’s support system, emotional state and
understanding of the process (Prine et al.,
2005).
Integration of MABs in to FPC:
Patient Support
• A survey of 148 urban women were
surveyed
– 70% agreed their clinic should provide MABs
– 73% (of those who would consider abortion)
would prefer to have it done by their family
physician.
Rubin et al, 2008
Integration of MABs in to FPC:
Patient Choice
• What might women choose if they receive
options counseling in a clinical setting that offers
on-site MABs and referrals for off-site surgical
TABs?
– A retrospective, cohort study of 204 women, in a
university setting, found 85% of eligible women chose
medication abortion. The earlier the gestational age,
the more likely a MAB.
– Reasons: convenience if both options are acceptable,
bias in physician counseling, self-selection of patients
Leeman et al., 2007
MABs within the Contra Costa
County Health Services
• Current Services
• Goals:
– Increase number of providers who offer MABs
– Establish an infrastructure and protocol to
support providers
– Model integration of MABs into FPC as part of
resident training
– Accomplish goals in a manner that is
respectful of differences in values
Establish Support: Non-resident
physicians/NP’s
• Identify interested providers, preceptors
– Qualifications
• FDA: must be able to reliably determine
gestational age.
• Need to be approved by OB/GYN to use US
• In-service training
Establish Support
1) Residents: 11 of 22 eligible residents
would like to incorporate MABs into their
FPCs.
2) Nursing: Organize values clarification
workshops to discuss concerns, if
needed.
3) Social Work: Entry way into the system
Clear, Accessible Protocol
• On-site info packets: medication guide,
mifeprex patient agreement, CCRMC
consent, provider note template, charting
template
• Dictate a procedure note
• Notify back-up OB-Gyns
• On call responsibility
• Follow-up visits
* Additional counseling resources available
for provider reference.
References
• Comparison of the Two types of First Trimester
Abortion. The Access Project.
• Chapter 3: Informed Consent, Counseling, and
Patient Preparation. NAF Abortion Textbook.
• Gamble et al. “Abortion Surveillance --- United
States, 2005.” MMWR. 2008; 57: 1-32.
• Leeman et al. “Can Mifepristone Medication
Abortion Be Successfully Integrated into Medical
Practices That Do Not Offer Surgical Abortion?”
Contraception. 2007; 76: 96-100.
• Prine et al. “Medication Abortion and Family
Physicians’ Scope.” Journal of American Board
of Family Medicine. 2005; 18: 304-306.
• Prine et al. “Medical Abortion in Family Practice:
A Case Series.” Journal of American Board of
Family Medicine. 2003; 16: 290-295.
• Rubin et al. “Patient Attitudes Toward Early
Abortion Services in the Family Medicine Clinic.”
Journal of American Board of Family Medicine.
2008; 21: 162-164.